I experienced visible hematuria twice over the past three days with urinary sediment, and three weeks ago completed a five‑day course of nitrofurantoin for a urinary‑tract infection that had a negative urine culture; what evaluation and management are recommended?

Evaluation of Recurrent Pink Urine After Treated UTI

You require urgent urologic evaluation with cystoscopy and upper-tract imaging (CT urography) because visible hematuria—even when self-limited—carries a 30–40% risk of malignancy and must never be dismissed. 1

Why Your Negative Culture Doesn't Change Anything

• A negative urine culture does not exclude serious urologic pathology; infection and malignancy can coexist, and the absence of bacterial growth simply means you didn't have a bacterial UTI at that time. 1
• The pink urine you saw three days ago represents gross (visible) hematuria, which automatically places you in the highest-risk category requiring complete evaluation regardless of age, sex, or other factors. 1
• Gross hematuria with sediment strongly suggests either upper-tract pathology (kidney stones, renal masses, urothelial carcinoma) or bladder pathology (transitional cell carcinoma, stones), all of which require direct visualization and imaging. 1

The Nitrofurantoin Course Is Irrelevant to Your Current Risk

• Nitrofurantoin does not cause hematuria; if bleeding occurred during or after treatment, it indicates underlying urinary-tract disease that the antibiotic may have temporarily masked or that coincidentally appeared. 1
• Even if you had a true UTI three weeks ago, the recurrence of visible blood now—especially with sediment—demands investigation because malignancy and infection frequently overlap. 1
• Do not accept another course of antibiotics without completing the urologic work-up first; empiric antibiotics delay cancer diagnosis and provide false reassurance. 1

What You Need Immediately

1. Confirm True Hematuria

• Obtain a fresh microscopic urinalysis on a clean-catch specimen showing ≥3 red blood cells per high-power field (RBC/HPF) to document true hematuria rather than pseudohematuria from foods, medications, or menstrual contamination. 1
• Dipstick testing alone has only 65–99% specificity and can yield false positives; microscopic confirmation is mandatory before proceeding. 1

2. Upper-Tract Imaging

• Multiphasic CT urography (unenhanced, nephrographic, and excretory phases) is the gold-standard imaging modality, with 96% sensitivity and 99% specificity for detecting renal cell carcinoma, transitional cell carcinoma, and urolithiasis. 1
• This single study evaluates your kidneys, ureters, and bladder in one examination and cannot be replaced by standard abdominal CT or ultrasound. 1

3. Cystoscopy

• Flexible cystoscopy is mandatory for all adults with gross hematuria to directly visualize the bladder mucosa, urethra, and ureteral orifices; imaging alone cannot exclude bladder cancer, which accounts for 30–40% of gross hematuria cases. 1
• Cystoscopy provides 87–100% sensitivity and 98–100% negative predictive value for bladder cancer, far exceeding any imaging modality. 1

Additional Laboratory Tests

• Serum creatinine to assess renal function. 1
• Urine culture (if not already done) to document any current infection before starting antibiotics. 1
• Examine urinary sediment for dysmorphic RBCs (>80%) or red-cell casts, which would indicate glomerular disease and require nephrology referral in addition to completing the urologic evaluation. 1

Common Pitfalls to Avoid

• Never ignore gross hematuria even if it appears self-limited or occurs only once; the 30–40% malignancy risk mandates urgent evaluation. 1
• Do not delay evaluation while treating a presumed UTI; infection does not explain visible blood with sediment, and systematic evaluation is required to avoid missed malignancy. 1
• Do not accept reassurance based on your age or the negative culture; gross hematuria requires the same comprehensive work-up in all adults regardless of demographics. 1

Timeline for Action

• Contact urology within 24–48 hours for same-week cystoscopy and imaging; delays beyond 9 months from first hematuria presentation are associated with worse cancer-specific survival in bladder cancer patients. 1
• If you develop recurrent visible blood, new urologic symptoms (flank pain, dysuria, urgency), or any systemic symptoms (fever, weight loss), seek immediate evaluation. 1